Lab 2 Vital Signs Notes

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Basic Health Assessment and Clinical Skills 2009 Vital signs

CLINICAL SKILLS Notes After the Lecture and Laboratory, students should be able to: 1. Describe the proper way for measuring the weight and height 2. Identify the landmarks and normal reference value for the vital sign measurement 3. Describe and demonstrate the correct method for collecting the vital sign data 4. List factors that affect the body temperature, pulse rate, respiration rate and blood pressure 5. Document the vital sign data and evaluate the data with the reference value 6. Relate the data with different developmental stages 7. Describe the following terms: Body temperature • Pyrexia, hyperthermia, fever, febrile • Hyperpyrexia • Intermittent, remittent, relapsing ,constant fever • Fever spike • Hypothermia Pulse • • • Respiration • • • • • • • • •

Tachycardia Bradycardia Dysrhythmia/ arrhythmia

Tachypnea & Bradypnea Apnea Dyspnea Orthopnea Cheye- Stokes breathing Hyperventilation & Hypoventilation Stridor, wheeze, bubbling Hemoptysis Productive cough, nonproductive cough

Blood Pressure • Hypertension- primary and secondary • Hypotension, orthostatic hypotension • An auscultatory gap • Korotkoff’s sounds

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Basic Health Assessment and Clinical Skills 2009 Vital signs

Weight and Height Height and Weight Table 5th Jarvis Frame size 5th Jarvis λ Weight ♦ Proper calibration of the electronic scale or balance ♦ Remove outer clothing ♦ Same time of the day, same kind of clothing ♦ Proper documentation λ Paediatric consideration ♦ Head circumference ♦ Chest circumference ♦ Gestational age Vital signs 1. 2. 3. 4. 5.

Body Temperature Pulse Respiration Blood Pressure Oxygen Saturation

BODY TEMPERATURE Glossary • Pyrexia, hyperthermia, fever, febrile- a body temperature above the usual range • A very high fever, such as 41°C- hyperpyrexia • Intermittent fever- temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures • Remittent fever- a wide range of temperature fluctuations more than 2°C occurs over the 24- hour period, all of which are above normal • Relapsing fever- short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature • Constant fever- the body temperature fluctuates minimally but always above normal • Fever spike- A temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours is called a fever spike • Hypothermia- a core body temperature below the lower limit of normal

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Basic Health Assessment and Clinical Skills 2009 Vital signs

The normal oral temperature with a range of 35.8°C to 37.3/37.5°C The common sites for measuring body temperature ♦ Oral ♦ Rectal- position  contraindicated for clients with myocardial infarction as ↑ vagal stimulation  contraindicated for clients who are undergoing rectal surgery, diarrhea or disease of rectum e.g. haemorrhoids ♦ Axillary- avoid in any ear infection ♦ Tympanic membrane Types of thermometers ♦ Mercury- in- glass thermometers  Long tip  Short rounded tip  Pear-shaped tip  Colour coded- red for rectal and blue for oral ♦ Electronic thermometers ♦ Chemical disposable thermometers, temperature-sensitive tape ♦ Infrared thermometers Procedure Purposes ♦ To establish baseline data for subsequent evaluation ♦ To determine changes in the core temperature in response to specific therapies Assessment ♦ Clinical signs of fever/ hypothermia ♦ Sites ♦ Factors that may alter core body temperature Equipment Thermometer Thermometer sheath or cover Water- soluble lubricant for a rectal temperature Disposable gloves Tissue/ wipes Implementation ♦ Check all the equipment is functioning normally ♦ Shake a glass thermometer down to below 35°C ♦ Explain to the client ♦ Wash hands and don gloves if necessary. Pay attention to the infection control procedure ♦ Place the client in the appropriate position

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Basic Health Assessment and Clinical Skills 2009 Vital signs ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

Place the thermometer in correct method Wait the appropriate amount of time Oral- 3 to 4 minutes to 8 minutes Axilla- 5½ minutes to 9 minutes Rectal- 2½ minutes Remove the thermometer and discard the cover or wipe with a tissue/ alcohol prep. Wash the thermometer for storage Document the temperature in the client record

Evaluation ♦ Compare the data and conduct appropriate follow-up

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Basic Health Assessment and Clinical Skills 2009 Vital signs

PULSES Glossary • Tachycardia- An excessive fast heart rate ( over 100BPM in an adult) • Bradycardia- A heart rate in an adult of 60 BPM • Dysrhythmia/ arrhythmia- a pulse with irregular rhythm •

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The normal pulse rate/ apical rate ( ref. to 5th Javis) Pulse Sites (ref. to 8th Kozier, p.538- p.546)) ♦ Radial ♦ Brachial ♦ Apical ♦ Femoral ♦ Popliteal ♦ Posterior tibial ♦ Dorsalis pedis

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Procedure Purposes ♦ To establish baseline data for subsequent evaluation ♦ To identify the pulse rate, rhythm and volume and compare the equality on each side Assessment ♦ Clinical signs of cardiovascular alterations e.g. dyspnoea, cyanosis ♦ Sites ♦ Factors that may alter the pulse rate Equipment Watch with a second hand If using a Doppler ultrasound stethoscope, the transducer probe, the stethoscope headset, transmission gel and tissues/ wipes Implementation ♦ Explain to the client ♦ Wash hands and don gloves if necessary. Pay attention to the infection control procedure ♦ Place the client in the appropriate position/ provide privacy ♦ Select the pulse point ♦ Palpate and count the pulse ♦ Assess the pulse rhythm and volume ♦ Documentation Using a DUS (Doppler ultrasound stethoscope) Evaluation

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Basic Health Assessment and Clinical Skills 2009 Vital signs

♦ Compare the data and conduct appropriate follow-up APICAL PULSE •

Procedure Purposes ♦ To establish baseline data for subsequent evaluation ♦ To obtain the heart rate of newborns, infants, and children 2 to 3 years old or of an adult with an irregular peripheral pulse ♦ To monitor clients with cardiac disease and those receiving medications to improve heart action Assessment ♦ Clinical signs of cardiovascular alterations e.g. dyspnoea, cyanosis ♦ Sites ♦ Factors that may alter the pulse rate Equipment Watch with a second hand Stethoscope Antiseptic wipes DUS Implementation ♦ Explain to the client ♦ Wash hands and don gloves if necessary. Pay attention to the infection control procedure ♦ Place the client in the appropriate position/ provide privacy ♦ Locate the apical pulse o Apex of the heart- point of maximal impulse (PMI) o Palpate the supersternal notch→ angle of Louis→2nd intercoastal space→5th intercoastal space → midclavicular line (MCL) (ref. to Kozier p. 543- p.546) ♦ Auscultate and count heartbeats o Disinfect the stethoscope and warm it before put on the client o Each lub-dub is counted as one heartbeat ♦ Assess the rhythm and strength of heartbeat ♦ Documentation Using a DUS Evaluation ♦ Compare the data and conduct appropriate follow-up

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Basic Health Assessment and Clinical Skills 2009 Vital signs

RESPIRATION Glossary • Eupnea- normal breathing Rate • Tachypnea- abnormally fast respiration • Bradypnea- abnormally slow respiration • Apnea- absence of breathing Volume • Hyperventilation- overexpansion of the lungs, rapid and deep breaths • Hypoventilation- underexpansion of the lungs, shallow breaths Rhythm • Cheyne- stokes breathing- rhythmic waxing and waning of respiration, from very deep to very shallow breathing and temporary apnea ( e.g. heart failure, ↑ICP, elderly) Ease or effort • Dyspnea- difficult and labored breathing • Orthopnea- ability to breath only in upright sitting or standing positions Breath Sounds • Stridor- a shrill, harsh sound heard during inspiration with laryngeal obstruction • Stertor- snoring, usually due to partial obstruction of the upper airway • Wheeze- continuous, high- pitched musical whistling when air moves through a narrowed obstructed airway • Bubbling- gurgling sounds, presence of secretions in the respiratory tract Secretion and coughing • Hemoptysis- the presence of blood in the sputum • Productive cough- a cough with expectorated secretion • Nonproductive cough- a dry, harsh cough without secretions • •

The normal respiratory rate (ref. to appendix, 5th Jarvis) Procedure Purposes ♦ To establish baseline data for subsequent evaluation ♦ To determine changes in the core temperature in response to specific therapies Assessment ♦ Skin and mucous membrane colour ♦ Position assumed for breathing ♦ Signs of cerebral anoxia (e.g. irritability, restlessness, drowsiness) ♦ Chest movements ♦ Breathing effort ♦ Medication affecting respiratory rate

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Basic Health Assessment and Clinical Skills 2009 Vital signs

Equipment Watch with a second hand or indicator Implementation ♦ Explain to the client ♦ Wash hands and don gloves if necessary. Pay attention to the infection control procedure ♦ Place the client in the appropriate position ♦ Count the respiratory rate after counting the pulses and do not need to emphasis to the client that his/ her respiration is being count as it may cause the client voluntarily altering the rate ♦ Observe the depth, rhythm and character of respirations ♦ Documentation Evaluation ♦ Compare the data and conduct appropriate follow-up

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Basic Health Assessment and Clinical Skills 2009 Vital signs

BLOOD PRESSURE Glossary • Hypertension- a blood pressure above normal • Hypotension- a blood pressure below normal • Orthoststic hypotension- a drop in systolic pressure of more than 20mmhg, and/or orthostatic pulse increases of 20bpm or more • An auscultatory gap- a brief time period when Korotkoff’s sounds diappear during auscultation of blood pressure; common with hypertension • Korotkoff’s sounds- When taking a blood pressure using a stethoscope, the nurse identifies five phases of sound in a series (ref. to appendix,Jarvis) • •

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The normal blood pressure ( ref. to 5th Kozier P.551-558, 8th Jarvis chapter 9 ) Sphygmomanmeter o Bladder o Aneroid (require calibration), mercury, electronic o Meniscus o Cuff size  the width should be 40% of the circumference  20% wider than the diameter of the midpoint of the limb  the length of the bladder- cover 2/3 of the limb’s circumference Blood pressure sites o Arm pressure  Common site o Thigh pressure  If the blood pressure cannot be measured on either arm  For comparison to detect aortic coartation o Special precaution  The limbs is injured or diseased  A cast or bulky bandage is on any part of the limb  Recent surgery of excision of the lymph nodes  Presence of Intravenous infusion  Presence of arteriovenous fistula Methods o Direct measurement- invasive monitoring o Indirect noninvasive method- auscultatory and palpatory Procedure Purposes ♦ To establish baseline data for subsequent evaluation ♦ To determine the client’s haemodynamic status ♦ To identify and monitor changes Assessment

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S/S of hypertension ( e.g. headache, flushing of face, nosebleed) S/S of hypotension (e.g. tachycardia, dizziness, confusion, cool and clammy skin, pale or cyanotic) Factors affecting blood pressure

Equipment Stethoscope Blood pressure cuff of the appropriate size Sphygmomanometer Implementation ♦ Check all the equipment is functioning normally ♦ Shake a glass thermometer down to below 35°C ♦ Explain to the client ♦ Wash hands and don gloves if necessary. Pay attention to the infection control procedure ♦ Place the client in the appropriate position o sitting with no crossing legs, lying, standing o elbow should be slightly flexed o palm of the hand facing up o forearm supports at heart level o expose the upper arm ♦ Wrap the deflated cuff evenly around the upper arm o locate the brachial artery o centre of the bladder apply over the artery o for an adult, the lower border of the cuff should be 2.5 cm or 1 inch above the antecubital space ♦ Initial examination- preliminary palpatory determination of systolic pressure ♦ Wait 1-2 minutes ♦ Position of the stethoscope – bell- shaped diaphragm ♦ Auscultate the blood pressure o Pump up the cuff until 30mmHg above the point where the brachial pulse disappeared palpatory o Release the valve at the rate of 2 to 3 mmHg per second o Identify the Korotkoff phases o Deflate the cuff rapidly and completely o Wait 1-2 minutes if remeasurement is required ♦ Remove the cuff ♦ Disinfection of the cuff ♦ Documentation Thigh pressure ♦ Prone position ♦ Posterior popliteal artery ♦ 20 to 30 mmHg higher systolic pressure than in the brachial artery

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Basic Health Assessment and Clinical Skills 2009 Vital signs Evaluation ♦ Compare the data and conduct appropriate follow-up

OXYGEN SATURATION

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Pulse oximeter o a noninvasive device that measures a client’s arterial blood oxygen saturation (SaO2) by means of a sensor attached to the client’s finger, toe, nose, earlobe or forehead o The photodetector measurement in peripheral artery blood and reports it as SpO2 o detect hypoxemia o Sensor LEDs- two light emitting diodes, one red, the other infrared, transmit light through nails, tissue, venous blood or arterial blood A photodetector placed directly opposite the LEDs to detect the amount of red and infrared light absorbed by oxygenated and deoxygenared haemoglobin in arterial blood o Normal SpO2- 95% to 100% o SpO2 < 70% is life threating o Pulse rate detection Factors affecting SaO2 o Haemoglobin o Circulation o Activity Procedure Purposes ♦ To establish baseline data for subsequent evaluation ♦ To detect the presence of hypoxemia before visible signs develop Assessment ♦ The best location ♦ The client’s condition ♦ Vital signs, skin and nail bed colour, tissue perfusion ♦ Adhesive allergy Equipment Nail polish remover Pulse oximeter Alcohol wipe Implementation

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Basic Health Assessment and Clinical Skills 2009 Vital signs ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

Check all the equipment is functioning normally Explain to the client Wash hands and don gloves if necessary. Pay attention to the infection control procedure Provide privacy Choose the correct sensor- nasal/ forehead sensor for poor perfusion Prepare the site Apply the sensor Set and turn on the alarm Ensure client safety- inspect tissue perfusion/ any signs of allergy Ensure accuracy of measurement- cover the sensor with a cloth if strong sunlight Documentation

Evaluation ♦ Compare the data and conduct appropriate follow-up